Why there are so few Groin Pain/Sports Hernia/Pubalgia Specialists

There are two questions the vast majority of my patients ask. The first is, why do I have this pain and how do I make it go away? The second is, why are you the only doctor in the New York Metropolitan area, maybe even the tri-state area, who takes care of this problem? My answer to the second question is usually a poor attempt at humor like, because I am the only surgeon in the area who is a glutton for punishment.

The question is truly reasonable, and it does deserve a reasonable answer. The easy answer, and the first that comes to mind, is that insurance companies do not regularly reimburse the physician or the patient for care relating to the injuries we see. They do not deny that people often experience groin pain, nor do they deny that there are patients with legitimate issues. But they do, regularly, refute the data regarding treatment and surgery for a Sports Hernia or Pubalgia. This stems from the fact that the data is, to this point, fairly scattered, and that the measures for diagnosis are still not settled. A large contingent of Surgeons themselves profess that they do not know of, or do not believe in, the entity of Sports Hernia or Pubalgia. It therefore becomes a self-perpetuating problem: medical professionals do not enter this aspect of the surgical field as they will not get paid, and will therefore not study or treat the entity. Thus, the number of people believing in and treating the entity will continue to remain low. Consequently, definitive studies, definitions, and diagnostic testing will continue to be scattered and inconsistent, and insurance companies will continue not to reimburse.

The second reason that few physicians enter this field is simply that it is rather hard. Don’t misunderstand me, I love this area of the body and I love the anatomy and the interplay between the different structures. But nonetheless, it is hard. Few patients have an easy diagnosis, and even fewer have an easy answer. Surgeons, by nature, desire hard data with definitive answers. This field, as stated above, is not yet definitive. Furthermore, General Surgeons are taught, from way back, not to operate for pain. We operate for a mass, a hernia, or a tear; all of which we can see on a scan. Pubalgia/Sports Hernias are often subtle findings and are at times, overlapping and not completely defined. To a General Surgeon, this is not always acceptable. Orthopedic Surgeons, on the other hand, operate for pain all the time. Theoretically, this falls into their comfort zone. However, by the fact that the spermatic cord, inguinal canal, and pubic tubercle are intimately involved with the problem, and Orthopedic Surgeons rarely if ever encounter these structures, the comfort zone is lost. Thus the problem remains in the hands of the few General Surgeons who desire to enter the Sports Hernia arena.

A final reason that Sports Hernia Specialists do not abound is that they depend upon other specialists and structures to exist nearby. To work-up and diagnose problems causing Chronic Groin Pain, there must be a very competent, progressive and open Musculoskeletal Radiology department which has access to a very up-to-date MRI machine. Additionally, the radiologist and surgeon must establish a defined Pubalgia Protocol to assess the structures in the groin. In the major centers which treat Chronic Groin Pain, there is an excellent relationship between the two disciplines. Similarly, as there is significant overlap between Pubalgia and Hip disorders, there needs to be a relationship between the Sports Hernia Surgeon and the Orthopedic Surgeon. A confluence of these disciplines, and significant input from Physical Therapists and Sports Trainers, ultimately create an effective group of people who help each other diagnose and treat Groin Injuries. This confluence, however, is not easily achieved, and often times, takes many years to build. Thus the Groin Pain/Pubalgia/Sports Hernia Specialist must have an intense enough interest in the problem to overcome each of these obstacles. In other words, a glutton for punishment.